Alcohol Misuse

Definition/ diagnostic criteria Alcohol misuse, also called alcohol use disorder (AUD) is characterised by an impaired ability to stop or control alcohol use despite adverse social, occupational or health consequences. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) previously differentiated alcohol abuse and alcohol dependence, but now applies a single category of AUD.

The term AUD therefore describes any pattern of alcohol use that involves regularly drinking above the UK chief medical officer guidelines of 14 units per week. AUD covers a spectrum, and is sometimes categorised into:

• Hazardous drinking (also called increasing risk drinking).
• Harmful drinking (also called higher risk drinking).
• Alcohol dependence.

It is important to note that physical withdrawal symptoms and tolerance do not need to be present to diagnose AUD.

Epidemiology In the UK, data show that in 2020 there were 8,974 alcohol-specific deaths (around 14 per 100,000 people). This is an 18.6% increase in deaths from 2019. This doesn’t include diseases such as cancer and cardiovascular disease, where alcohol is a significant attributable fraction.

A UK Office for Health Improvement and Disparities analysis for the Local Alcohol Profiles for England estimated that in England, just over 21% of the adult population are drinking above the recommended low risk guidelines. This consists of:

• 2 million (17.7% adult population) drinking at hazardous levels.
• 7 million (3.6% adult population) drinking at harmful levels.
• 6 million (1.4% adult population) who are alcohol dependent and potentially in need of specialist alcohol treatment (this group is a subgroup mostly of the group of people who are drinking harmfully).

In England, there are an estimated 602,391 dependent drinkers (2018-19) of whom 82% are not receiving treatment.

Diagnosis AUD is diagnosed using validated screening tools such as the 10-question AUDIT (Alcohol Use Disorder Identification Test), although the three-question AUDIT-C can be used for initial screening, with the other seven AUDIT questions being completed if the AUDIT-C is positive.

While a significant proportion of patients attending primary care services are drinking at levels that risk harm to their health, alcohol use is often not the presenting factor. It should be considered and screened for whenever a condition linked to alcohol is diagnosed. Public Health England’s 2016 The public health burden of alcohol: evidence review found more than 60 health conditions associated with harmful drinking and alcohol dependence. Common alcohol-related health conditions include:

• Alcohol-related liver disease.
• CVD, including hypertension.
• Gastro-oesophageal reflux disease.
• Mental health conditions, including anxiety and depression.
• Increased risk of self-harm, including suicide.
• Cancers including oral cavity, pharynx, oesophagus, larynx, breast colorectal.
• Alcohol related brain damage including Wernicke-Korsakoff syndrome.

Primary care can help reduce alcohol related harm by:

• As per the GP contract, screening new adult patients to routinely identify people with alcohol use disorders, using a validated screening tool and providing brief interventions at an early stage. Also by doing this opportunistically.
• Referring patients who are probably dependent, and those with alcohol-related health conditions to specialist alcohol treatment services.
• Supporting alcohol treatment services by arranging access to blood tests and providing results of these. Note that while blood tests, particularly LFTs, have value in the management of AUD, they are not in any way diagnostic and the presence of normal LFTs does not exclude significant hepatic disease.
• The presence of cirrhosis in those with AUD is best assessed via transient elastography [Fibroscan].

Stigma or fear of stigma can play a significant part in patients’ reluctance to discuss their alcohol consumption. However, they are unlikely to object to alcohol-related questions if performed:

As part of a routine examination such as:

• New patient check.
• Chronic disease management, e.g., diabetes, CHD, hypertension, depression.
• Medication reviews.

Opportunistically, such as:

• When explained that alcohol could be a cause of or exacerbate the presenting symptom/condition.
• Before prescribing a medication that interacts with alcohol.
• In response to a direct request for help.
• Following recent emergency care attendance.
• During a request for emergency contraception.

Treatment Most people with an AUD do not need specialist alcohol treatment but may benefit from alcohol brief interventions (ABI), sometimes known as screening and brief interventions aimed at supporting behavioural change.

Any trained healthcare practitioner can offer identification using a validated tool and structured brief advice in 10 minutes. Structured brief advice should include:

• Exploring the current level of drinking.
• Feeding back on the potential harms resulting from this.
• Simple advice on ways to cut down, such as switching to lower strength alternatives and alternating soft and alcoholic drinks, if possible supported with an appropriate leaflet.

Primary care teams play a significant role in managing the comorbidities relating to alcohol use and in supporting community based medically assisted withdrawal supervised by local alcohol treatment providers, and the subsequent provision of relapse prevention medication such as acamprosate and naltrexone. These are recommended in the NICE guidelines for use in primary care and can be taken for up to 12 months with the aim of maintaining abstinence. Empirical opinion also suggests they reduce the number of heavy drinking days should a patient lapse and can prevent a lapse becoming a full-blown relapse.

A low threshold should be in place for prescribing oral thiamine given the severe consequences from unmanaged withdrawal; this should be continued for 6 weeks after abstinence. In some cases where the patient has very poor nutritional status and is felt to be at risk from an unmanaged withdrawal the administration of an intramuscular preparation can be appropriate. Acute alcohol withdrawal carries a risk of significant morbidity and mortality from seizures, Wernicke’s encephalopathy and delerium tremens and admission to hospital is appropriate.

Psychosocial interventions are a key part of treatment, and these can be delivered via the local alcohol treatment teams, ideally within the surgery setting to reduce stigma. Many patients will also benefit from peer support such as AA (Alcoholics Anonymous) or SMART (Self-Management and Recovery Training). Evidence suggests engagement and outcomes are better if this is supported and encouraged early in the treatment process.

GPs and their teams can also help support a patient’s recovery from alcohol dependence by:

• Working with alcohol treatment services and sharing information with the patient’s consent.
• Contributing to multidisciplinary, multi-agency care planning, risk management and safeguarding for patients with multiple and complex needs.
• Offering harm reduction advice and interventions to patients who continue to drink at harmful or dependent levels. The vast majority of physical health harms related to alcohol are dose dependent, so any reduction in overall consumption is to be encouraged.
• Helping family members to access support provided by the local alcohol service. It can be very stressful for carers/families when someone continues to drink and won’t accept referral to treatment services. Sectioning under the Mental Health Act isn’t an option if AUD is the only condition involved.
• Reducing barriers to accessing primary healthcare for all people with alcohol problems, including socially excluded people and communities experiencing the worst health outcomes.

Prognosis Alcohol screening and brief intervention has a strong evidence base and is effective with a significant number of patients reducing or even ceasing alcohol consumption. However, these interventions despite being quick, simple and low cost need to be delivered on a much wider scale to effect population level change.

For more severely affected patients AUD is usually chronic, and while treatment is beneficial, relapse is common, particularly in the first 12 months after starting treatment. This is where ongoing engagement with the primary care team is particularly valuable. Many patients will need to undergo medically managed withdrawal or psychosocial interventions more than once and this option should remain available to them.

Written by Dr Steve Brinksman,  a former GP and Medical director, Cranstoun